My Claim Has Been Denied, Now What?

When you or a family member visits a doctor it’s usually for routine care. But, there may be a time when you or a family member needs medical care that involves ongoing doctor visits, out-patient care or a hospital stay. The last thing you want to worry about is a denied claim. To know if a claim is denied you will find the details on your Explanation of Benefits (EOB).

 If a claim is denied you have the right to submit an appeal. Anyone can submit an appeal, which is a way to have that decision reviewed.

Also, keep in mind that there are different appeals that are reviewed by separate groups within your health insurance company.

  • A provider appeal is made by your doctor or the facility that is delivering your care. Most often this is about the length of stay or treatment that was denied. This appeal is something that you might want to discuss with your doctor. The doctor/clinical peer review process takes 30 days and leads to a written notice of appeal status. 
  • A non-clinical appeal is filed when you want your insurer to reconsider a previous complaint or action. This relates to administrative health care services such as your membership, access, or claim payment. This review is performed by a non-medical appeal committee.
  • A clinical appeal is asking to reverse a ruling for care or service that was denied because it wasn’t considered medically necessary, or if the services were considered experimental or cosmetic. This may be pre- or post-service. The review is carried out by a doctor.
  • Urgent care or expedited appeals take place if you, an authorized representative or doctor feels that denial of services may seriously risk your health. The doctor or facility may ask for an expedited appeal.

What if you can’t appeal?
You can have an authorized representative, doctor, facility or other health care practitioner submit an appeal for you. But you need to give written or verbal permission for someone else to submit your appeal, unless it’s an urgent care appeal.

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